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FOR OFFICE USE: _ FOR OFFICE USE: °/�li17-- io APPLICATION FOR SANITATION PERMIT ---'----"--'--- - Permit No -- - Cg } 2- (Complete in Triplicate]-------------------------------- r------- iplicate] 7 /�� 7f-"---- , S~ _ This-Permit-Expires-r1,Year-From Date-Iss Date Issued_ �. I! A 1� ( ,.f 110 Y 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work.herein described. xThis application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA T N--- --- _DC ._1_� 1 F - ��i�7`�.{e�----+�Y__- - - - CENSUS TRACT--------------------------------- Owner's ----- ------- -------- '--k-.._.Owner's Name----- e N- _ D077 ---=------- -------------------------'--�---------- ......Phone" : -----. IL Address----- ---- '=---------n----:-------- " f�� :.- B�LQe- �` _-_------City- ` Zip Contractor's Name---,l:✓Y--:- . - -- A_-' ,-__-'- '---- - "-- License #•� ` ----Phone`__ K6�` 6-0 --- Installation will serve: Residen Apartment H use ❑ ,Commercial ❑ Trailer Court ❑ fj Motel - ��Other- �"4,a—,0-_: . _ F 4 Number of living units:__' _____Number of bedrooms.__________.Garba.ge Grinder__-'___._°__Lot; ize._.___`_ . ______.___._ i, Water Supply: Public System and name -?'f ��: ::._ ... ' : :_ -------------------------------------Privatee _ _ - --- Character of soil to a depth of 3 feet: Sand ❑ Silt❑ :Clay, ❑ [ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan Adobe' _. ._ 1` p ❑ Fill Material If yes, type-- : ----'---- (Plot plan, showing size of lot, location of system in relation to=wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or'•se p ge ,pit permitted if public sewer is•ava li able within 200 feet,} t PACKAGE TREATMENT [ '] SEPTIC TANK" 1 Y Size---_._ _� r J .�---< Liquid Depth. Capacity--t_ .0' _ T'ype=- ------ _._Mater1ala!Zy� _--,_No. Compartments.---- ----------- --- a : ; = Distance*to nearest;_W.ell-��.:..........................:.Foundation...�� .--_...........Prop. Line------/_��~______`- LEACHII1fa LINE No. of Li`nes---I-__"--'- ------'---- _Len hof each lin®- ----------- "--.Total Length.-------f--6 --__ -- _-- D' Box.-t__-- .-Type Filter Materia4t"J +?Depth Filter Material__ ...`--d----------------------- ! � e (t � 5 -� '� --- -- ------ perty Line - 1 -----------'- Distance to nearest: Well_ �" Fondatlon_____ Pro i SEEPAGE PIT `F/M� Depth_.. - Diameter- a�._ __ Number__ '�yk4.; ""___"_" __:_ ' r Rock Filled Yes No F' Water Table,Depth 9__*�:__ _ Rock Size._t Z- 7h -- - F �. Distance to neares : Wel1---------_-��-=------ ------•------:------Foundcition--..-- - ------ Prop. Line.------Za- ------' F 4 REPAIR/ADDITION (Preva Sanitation Permit# -- Date___"_�+ - -- Septic } t Tank [Specify Requirements} "` ---- - ---------- ---- ------- ----- ----------------- -•----- -- DisposalField (Specify quire ents) --- -`--'- '-'----'._---:---------------------------------------------- - ----- -------------------------- ---------------------------- ;--.. r ' ----e---------------------------- - - - - ------------ -- ---------'----'--------- ------------ - - -r- -- -- -- ---- ----- - ---- ----------------------------------- ---------- 4 t ` (Draw existing arid required addition on reverse side) I hereby certify that I have-prepared-this application and that the-.work will be done 1n accordance with San Joaquin County Ordinances,' State Laws; and Rules and Regulations of the- San Joaquin Local Health District, Home owner or licensed-agents signature certifies the following: "I certify that'in the'perfoyfiianci of the work for which this permit is issued,.[ shall -not employ''any person in such manner as to becometett to. kman's ntpens tion laws F California."_ Signed t 4 By = = - - -- - - - /s3 tle- ------------------- - - d ( 1 (If other than owner) � " � - � � - �� -FOR DEPARTM§INT USE ONLY APPLICATION ACCEPTED-BY ---------------------- -------= DATE._ : DIVISION-QFL""AN - D NUMBER -- -- _ �. _ �"t �� DAT 4 E' ADDITIONAL COMME�NTS�_��"._. 77."" ._ - ----------- - ------ ------ --------------------- - F Y`n . { -,-�--- -} _ ` n . -------------- - --- - -w 3 .a ------- -------- — — ------------------------------------------_ Final-Inspection^- f� ------------------------------------------------------------ ---------•------- - ' ' bY•- ---- ��------- - --- ---------------------Date /� _ _ �7 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7/76 San